Patient-Driven Payment Model (PDPM)

The Patient-Drive Payment Model (PDPM) is scheduled to begin Oct. 1, 2019, and AANAC is here to help!

The Centers for Medicare & Medicaid Services released the Fiscal Year (FY) 2019 Skilled Nursing Facility Prospective Payment System (SNF PPS) final rule, which solidified their plans to implement PDPM.  PDPM is set to replace the RUG-IV case-mix classification model that has been the hallmark of SNF PPS for years. This new payment system will be unlike anything SNFs have seen before! You and your staff have a lot to do to get ready for PDPM, and AANAC will be with you the entire way.  Visit this page frequently to get tools, education, and resources to help you lead your team readiness.

  • Sept. 19 SNF/LTC Open Door Forum Agenda and Call-in Info

    By CMS - September 11, 2019

    The next CMS Skilled Nursing Facilities (SNF)/Long Term Care (LTC) Open Door Forum scheduled for:  

    Date:  Thursday, September 19, 2019

    Start Time:  2:00 PM – 3:00 PM Eastern Time (ET);

    Please dial-in at least 15 minutes before call start time.

    Conference Leaders: Todd Smith & Jill Darling

    **This Agenda is Subject to Change**

    I.   Opening Remarks

    Chair – Todd Smith (Center for Medicare)

    Moderator – Jill Darling (Office of Communications)

    II.   Announcements & Updates

    *PDPM Update

    *PBJ Update

    *Policy Questions should be sent to: NHStaffing@cms.hhs.gov

    *Technical Issues/Questions should be sent to: NursingHomePBJTechIssues@cms.hhs.gov

    *PBJ Website: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Staffing-Data-Submission-PBJ.html

    * CMS-6058-FC Medicare, Medicaid, and Children's Health Insurance Programs; Program Integrity Enhancements to the Provider Enrollment Process

    *SNF QRP resource update

    III. Open Q&A

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  • CMS Makes Direct Link Between Outcomes and Medical Review

    By Caralyn Davis, Staff Writer - September 11, 2019

    Under the Patient-Driven Payment Model (PDPM), resident outcomes will be key to avoiding medical review, said officials with the Centers for Medicare & Medicaid Services (CMS) during the August 14 Skilled Nursing Facility Quality Reporting Program (SNF QRP) training session, Patient-Driven Payment Model: What Is Changing (and What Is Not). Note: Find the session slides here.

     

    The goal of PDPM is for SNFs to provide value-driven care, said officials. “Fundamentally, it comes down to a balance. A high-value and efficient provider is one that is able to achieve high-quality outcomes at low cost.”

     

    CMS measures SNF quality of care in three main ways:

    • The SNF QRP;

    • The Skilled Nursing Facility Value-Based Purchasing (SNF VBP) program; and

    • The Five-Star Quality Reporting System on Nursing Home Compare.

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  • Final PDPM Grouper DLL Released (9/19)

    By CMS - September 09, 2019

     

    The FINAL version of the PDPM Grouper DLL has been posted, along with its source code.  Note that the DLL interface has not changed since the beta version. Documentation and test files will be provided in a separate posting – coming soon. Please report any issues found to PDPM@cms.hhs.gov.
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  • Interrupted-Stay Policy: CMS Clarifies Noncovered Days

    By Caralyn Davis, Staff Writer - September 04, 2019

    Under the Patient-Driven Payment Model (PDPM), the Centers for Medicare & Medicaid Services (CMS) will implement an interrupted-stay policy for the first time in the Skilled Nursing Facility Prospective Payment System (SNF PPS). The agency is already ironing out some potential bumps in the implementation process. Following the release of the draft v1.17 Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, CMS has clarified the new policy to account for the difference in how the day of discharge is treated for Part A residents who physically discharge from the SNF vs. those who discharge from Part A and remain in the building (e.g., as a Medicaid resident).

     

    CMS officials reviewed key aspects of the interrupted-stay policy, including this new clarification that impacts the count of noncovered days, during two sessions at the August 14 Skilled Nursing Facility Quality Reporting Program (SNF QRP) training event: Section A, I, J, and O Updates and Patient-Driven Payment Model: What Is Changing (and What Is Not). 

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  • FY 2020 PDPM ICD-10 Mapping Tool and MDS Item I0020B ICD-10 Code Lookup Tool (9/19)

    By CMS - September 03, 2019

    CMS has released the PDPM ICD-10 Mappings File for FY 2020 as well as the I0020B Code Lookup File. 

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  • PDPM FAQs and Fact Sheets_Revised (9/19)

    By CMS - September 03, 2019

    Fact Sheets

    This section includes fact sheets on a variety of PDPM related topics.

    • Administrative Level of Care Presumption under the PDPM
    • PDPM Payments for SNF Patients with HIV/AIDS
    • Concurrent and Group Therapy Limit
    • PDPM Functional and Cognitive Scoring
    • Interrupted Stay Policy
    • MDS Changes
    • NTA Comorbidity Score
    • PDPM Patient Classification
    • Variable Per Diem Adjustment

    PDPM Frequently Asked Questions

    This section contains frequently asked questions (FAQs) related to PDPM policy and implementation.

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  • Final MDS 3.0 Data Specs for Oct. 1, 2019 Implementation (8/19)

    By CMS - August 21, 2019

    The FINAL version (V3.00.1) of the MDS 3.0 Data Specifications was posted.  This version is scheduled to become effective October 1, 2019.  Note that there have been additional revisions since the errata – they can be identified by looking for “post-errata” in the version notes for the items and edits.

    In addition,  V1.04.0 of the MDS 3.0 CAT Specifications  is also scheduled to become effective October 1, 2019. The specification for CAT 12 (Nutritional Status) has been updated in accordance with the changes in V3.00.0 of the MDS 3.0 Data Specifications.
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  • Under PDPM, Group/Concurrent Therapy Will Need NAC Case Management

    By Caralyn Davis, Staff Writer - August 13, 2019

    When the Patient-Driven Payment Model (PDPM) implements this October 1 in the fee-for-service Medicare Part A Skilled Nursing Facility Prospective Payment System (SNF PPS), concurrent therapy, group therapy, and even restorative nursing will once again take on a renewed importance as tools for achieving a resident’s clinical goals, says Joel VanEaton, BSN, RN, RAC-MT, vice president of compliance and regulatory affairs for Broad River Rehab in Asheville, NC.

     

    “However, you may run into trouble if SNFs or therapists simply dictate, ‘We will do X amount of concurrent and group therapy,’” suggests VanEaton. “PDPM is intended to be a reimbursement system that elevates the resident’s voice by ensuring that resident care decisions appropriately reflect each resident’s actual care needs.”

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  • 2020 ICD-10-CM Diagnosis Code Files and Coding Guidelines (8/19)

    By CMS - August 12, 2019
    The 2020 ICD-10-CM files  contain information on the ICD-10-CM updates for FY 2020. These 2020 ICD-10-CM codes are to be used for discharges occurring from October 1, 2019 through September 30, 2020 and for patient encounters occurring from October 1, 2019 through September 30, 2020. This also contains the official ICD-10 Coding Guidelines.
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  • PDPM At-a-Glance Tool

    By AANAC - August 07, 2019
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  • First Comes PDPM, Then Comes a SNF QRP Tsunami

    By Caralyn Davis, Staff Writer - August 02, 2019

    Nurse assessment coordinators (NACs) won’t be able to take much of a breather following the October 1, 2019, implementation of the new Patient-Driven Payment Model (PDPM) case-mix classification system for the fee-for-service Medicare Part A Skilled Nursing Facility Prospective Payment System (SNF PPS). NACs will have exactly one year to get comfortable with PDPM before their interdisciplinary team has to begin submitting data for 59.5 new Standardized Patient Assessment Data Elements (SPADEs) across the PPS admission and PPS discharge assessments that will be required under the data submission threshold requirement for the Skilled Nursing Facility Quality Reporting Program (SNF QRP). This includes four SPADEs that will be used to calculate and check the logic of two new MDS-based SNF QRP quality measures (QMs) involving the Transfer of Health Information IMPACT Act domain.

    One of the few breaks NACs received in the Fiscal Year (FY) 2020 SNF PPS Final Rule is that CMS has put off plans to expand the SNF QRP to all SNF residents regardless of payer source. Here are the highlights NACs need to know about.

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  • Spelling Out the Differences Between the IPA and SCSA

    By Jessie McGill, RN, RAC-MT, RAC-MTA - August 01, 2019

    The Significant Change in Status Assessment (SCSA) may be considered an “old dog” in the assessment world, but we will need to learn new tricks under the Patient-Driven Payment Model (PDPM). While the SCSA is an OBRA assessment, historically it could count as a PPS assessment, and could therefore affect payment when completed during a resident’s Medicare stay. Under PDPM, that is no longer the case. The newly-introduced Interim Payment Assessment (IPA) will be the only assessment, beyond the 5-day, that will be able change a resident’s Medicare rate. While this assessment seems to have similarities to the SCSA, nurse assessment coordinators (NACs) must understand the key differences for criteria, scheduling, timing, and payment and survey implications to ensure success under PDPM.  

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  • Finetune Section GG Coding to Prevent Inaccurate Payments

    By Caralyn Davis, Staff Writer - August 01, 2019

    In the current RUG-IV case-mix classification system used in the Medicare Part A Skilled Nursing Facility Prospective Payment System (SNF PPS), the activities-of-daily living (ADL) score derived from MDS section G (Functional Status) factors into the calculation of every case-mix group. Effective October 1, that all changes. While section G will still be important for care planning and some quality measures (QMs), section GG (Functional Abilities and Goals) will take over on the payment front, providing functional scores that will be used in case-mix classification for three of the five case-mix-adjusted payment components under the new Patient-Driven Payment Model (PDPM): physical therapy (PT), occupational therapy (OT), and nursing.

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  • FY 2020 SNF PPS Final Rule Link and Fact Sheet (7/19)

    By CMS - July 30, 2019

    The Centers for Medicare & Medicaid Services (CMS) issued a final rule [CMS-1718-F] for Fiscal Year (FY) 2020 Medicare payment rates and quality programs for skilled nursing facilities (SNFs). This final rule is part of the agency’s continuing efforts to strengthen the Medicare program by better aligning payment rates for these facilities with the costs of providing care and increasing transparency so that patients are able to make informed choices. The final rule [CMS-1718-F] can be downloaded from the Federal Register at: https://www.federalregister.gov/documents/2019/08/07/2019-16485/medicare-program-prospective-payment-system-and-consolidated-billing-for-skilled-nursing-facilities.

    OVERVIEW

    This fact sheet discusses three major provisions of the final rule:

    ·        SNF payment policy under the SNF Prospective Payment System (PPS)

    ·        SNF Value-Based Purchasing Program (VBP)

    ·        SNF Quality Reporting Program (QRP). 

    This final rule includes policies that continue to move forward agency commitments to shift Medicare payments from volume to value, with the continued implementation of the SNF VBP and SNF QRP to improve program interoperability, operational quality and safety.

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  • CMS May 7 and 8, 2019, SNF QRP Post-Training Videos and Slide Sets Available (7/19)

    By CMS - July 29, 2019

    Videos and post-training materials (includes answers to knowledge checks and interactive sessions) from the May 2019 Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) Provider Training held in Kansas City, MO, on May 7 and 8, 2019, are now available.

    Please note: Post-training materials include answers to knowledge checks and interactive sessions. Additionally, Section GG presentation has been updated to include links to videos shown during the training.

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